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Jan 8 2018 – Dementia Case

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Download Document: Case Recommendations Jan 8 2018

Date: January 8 2018

PLEASE NOTE that Project ECHO® Care of the Elderly case recommendations do not create or otherwise    establish  a  provider-patient relationship between any   ECHO Care of the Elderly Hub team member/presenters and any patient whose case is being presented in a Project ECHO® setting.

Case Synopsis:

The patient is a 49 year old woman with frontotemporal dementia and significant behavioural issues. The case presenter requested a review of her behaviour management and pharmacotherapies.

Summary of Recommendations:

  1. Pain management: May consider reassessment of pain-neuropathic/post herpetic neuralgia, muscular, osteoarthritis (Resources below: PAINAD, Abbey pain scale, DOS charting, Research study Pain vs antipsychotic link )
    1. Recommend Trial of Regularly administered Acetaminophen to start
    2. May consider increasing Nortriptyline for neuropathic pain, with caution re: risk of delirium with increased anticholinergic load
    3. May also consider augmentation with gaba/pregabalin or retrial of low dose narcotic such as hydromorphone
    4. Alternatively may consider nabilone but evidence in dementia not evidenced based at this time
  1. May consider the patient’s behavior as having components of a compulsive disorder, thus may consider Imipramine instead of Nortriptyline, noting potential side effects .
  2. Hx of Bipolar disorder: may consider trial of Carbamazepine, good evidence that it can be effective with behaviours, however several drug interactions.
  3. Venlafaxine can be more activating, may consider tapering.
  4. Review Goals Of Care and Quality Of Life : Rosuvastatin and calcium may be of no benefit particularly if Rosuvastatin is being used for primary prevention, may consider discontinuing to decrease pill burden.
  5. Non-pharmacological interventions:
    1. Individualized toileting schedule, increased mobilization less time in the gerichair, baby gates on doorways, TV programs she enjoyed on infinite loop
    2. Stimulus response: May consider positively reinforcing the behavior you want (does she have a favorite food that could be used for this).
    3. Social Support: Friendly visiting program, volunteers.
  6. Caregiver supports – Referral of family to caregiver support group and/or education around benefits of their visits. For younger children see Resources below: NICE website, “When Dementia is in the House”.


1. DOS Tool – printable

2. PAINAD – printable – online calculator

3. Abbey Pain Scale – printable – online calculator

4. When Dementia is in the House – printable – online resource

5. Carbamazepine for tx of bipolar disorder:

6. Pain management in patients with dementia:

7. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia:  cluster randomised clinical trial: